A Rare Combination of Gastric Inflammatory Fibroid Polyp and Hiatal Hernia

doi:10.4236/ss.2011.27080

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Surgical Science, 2011, 2, 366-368

doi:10.4236/ss.2011.27080 Published Online September 2011 (http://www.SciRP.org/journal/ss)

A Rare Combınation of Gastric Inflammatory Fibroid

Polyp and Hiatal Hernıa

Coskun Polat, Murat Burc Yazicioglu*, Serkan Turel, Mehmet Nuri Kosar, Yuksel Arikan

Departme nt of Surgery, Afyon Kocatepe University, School of Medicine,

Afyonkarahisar, Turkey

E-mail: *[email protected]

Received March 8, 2011; revised May 13, 2011; accepted August 10, 2011

Abstract

Inflammatory fibroid polyp (IFP) is a rare solitary gastrointestinal lesion of unknown etiology. It generally

presents as polypoid mass in the gastric antrum. Mostly affects adults at average age of 60 years. IFP can

cause different symptoms such as abdominal pain, gastrointestinal bleeding, intestinal obstruction or

intussusception. IFP is a bening lesion and it may rarely mimic the submucosal tumor. The diagnosis can be

possible after removal of the detected lession either by laparoscopic or open approach. In the present paper,

we report a patient with gastric IFP and hiatal hernia. IFP was excised throughout the gastrotomy and

following hiatal hernia was repaired. According to our best knowledge, this may be the first case report of

gastric IFP concomitance with a hiatal hernia.

Keywords: Gastric Inflamatuary Fibroid Tumor, Vanek, Diagnosis and Treatment

1. Introduction

Inflammatory fibroid polyp is a relatively rare disorder

which is thougt to b e clin ically an d histo logically ben ig n,

and was first described as “polypoid fibroma” in 1920 by

Kojetzny [1]. It may occu r throughou t the digestiv e tr act ,

but is most often seen in the stomach (approximately

80%) and usually occured either in the antrum or

prepyloric region [2]. It is slightly more common in

women (female:male ratio 1.6:1) [3]. It can be encoun-

tered in all age group but peak incid ence is between sixth

and seventh decades [4]. IFP originates from submucosa

and grows as a solitary polypoid or sessile mass which

may macroscopically mimic gastric cancer. When it is in

the stomach, most frequently seen symptoms are

vomiting, epigastric pain and bleeding. The lesion lo-

cated in the small bowel can cause intussusception and

obstruction. The diagnosis of IFP remains difficult be-

cause of all available methods such as barium swallow or

even endoscopic with endo scop ic ultrasonog raphy (EUS )

provide only nonspesific, insufficent information. In the

case of submucosal lesions, standard biopsies are in-

sufficent in obtaining adequate tissue. So that endo-

scopic tumor excision or laparotomy is recommended. In

this paper, we aimed to report a patient with IFP and

hiatal hernia and to review the literature.

2. Case Report

A 75 year-old man was referred to our hospital with

complaints of nausea, abdominal pain and distention

which was known for three years. Endoscopic exami-

nation had been performed from the same complaints

three years ago. En doscopy revealed a hernia poch at 7th

cm below the Z line, and a 5 - 6 cm diameter of hiatal

hernia and stomach was torsionized from this bare area.

We could not perform endoscopic biopsy, because of the

severe elevation in his arterial tension. A barium swallow

was recommended, but he accepted neither barium

swallow nor treatment. In his last admission, endoscopic

examination showed a giant hiatal hernia, chronic

gastritis and a mass in the bulbus; then multiple biopsy

was obtained. On histhopathological examination, chronic

inflammation and erosion were seen. Computed tomo-

graphy (CT) revealed a giant hiatal hernia and a 2 × 7 cm

hypodense image in hernia bowel which was close to

liver at the right side (Figure 1).

In his history, he was operated for Benign Prostate

Hipertrophy and right inguinal hernia. No spesific family

history was identified. On laboratory examination, WBC

was 13,800/mm3.

We have decided to perform an exploratory lapa-

rotomy and Nissen fundoplication, because of he had a

C. POLAT ET AL.

367

Figure 1. A giant hiatal hernia shown by CT.

giant hiatal hernia concomita nce with a gastric tumor. At

laparotomy, a 5 × 3 cm mass was found at the antrum of

the stomach. It was excised after a gastrotomy was

performed at the region of prepyloric antrum. In the

frozen section, there were no malign cells at the base-

ment of the lesion. Histopathologic evaluation of the

specimen demonstrated a fibroblastic stroma with exten-

sive thick-walled capillary vessels, spindle cells, and an

inflammatory infiltrate with numerous eosinophils within

the submucosa (Figure 2).

3. Discussion

IFP arises from submucosa of the gastrointestinal tract. It

consists of loose connective tissue with a rich vascularite

and abundant fibrous component [5]. Usually the lesion

was sessile or polypoid with ulceration of the overlying

mucosa [6]. IFP was mainly located in the pyloric region

of the stomach, less frequent in the ileum, and only occa-

Figure 2. Radiologic view of mass in the stomach.

sionally in the colon or oesophagus. IFP is non-neoplas-

tic in nature and its cause remains unclear [6,7]. Eosino-

philic infiltration which sometimes may occur as a sub-

mucosal tumor was also related to parasitic infections

such as gastric anisakiasis [8,9].

The clinical presentation and the radiological findings

of IFP may change to the size of the lesion and location.

Small lesion is usually asymptomatic until the occur-

rence of pyloric stenosis or small bowel obstruction [5].

Although they are usually small and asymptomatic, it

can cause gastrointestinal bleeding, abdominal pain,

vomiting, weight loss, intestinal obstruction or intus-

susception. Physical examination is usually not conclu-

sive and imaginings such as upper GI series, ultrasono-

graphy or CT can help diagnosis. Final diagnosis is

generally based on endoscopy and histopathological

examination.

Histopathologically, IFP has been found to be charac-

terized by a submucosal lesion with a mixture of prolif-

eration of fibroblasts and small blood vessels, accompa-

nying a marked eosinophilic infiltration [10]. Since the

distinctive structures for diagnosis are located within the

submucosa and at the base of the mucosa, the diagnosis

may not be possible in most of these polyps by endo-

scopic biopsy specimen [2].

The etiopathogenesis of IFP remains unclear. It has

been hypothesized that several factors could damage the

gastrointestinal mucosa and expose the stroma to several

irritants (chemical, mechanical and biological), and

stimulate the formation of polyps among certain people

[11]. A polyp of this category is a specific response of

gastrointestinal stromal tissue of unknown etiology [2].

Electron microscopic study revealed that IFP represented

a reactive lesion of myofibroblastic nature [12]. Tod ay, it

has been now generally accepted that IFP is not a neo-

plasia, but a reactive process, either to an allergy or a

foreign body and has no malignant potential [13,14]. A

few recent studies also revealed a relation between IFP

and H. pylori infection but an infective ethiology has

never been reported yet [11]. In one of these reports, the

patient also had an autoimmune diseases (sarcoidosis,

rheumatoid arthritis, and ankylosing spondylitis) [15].

This finding supports the possibility of an immunological

reaction as a contributing factor.

The majority of gastrointestinal polyps can be diag-

nosed and treated by endoscopically. This may be per-

formed at a single sitting or as a staged prodecure after

biopsy. The problem with submucosal lesions is the low

probability of obtaining a definite biopsy. If the tumor is

larger than 4 cm, there may be ulceration of overlying

mucosa, making biopsy easier. Endoscopists should al-

ways suspect submucosal mesenchymal tumors of being

gastrointestinal stromal tumour, leiomyoma or leiomyo-

C. POLAT ET AL.

368

sarcoma especially when tumor macroscopically mimics

a malignant lesion. Biopsy specimens using standart for-

ceps may not be adequate for histological diagnosis

when tumor is covered with normal mucosa. Then endo-

scopic excision/polipectomy preceded with endoscopic

ultrasonography should be performed as the best diagnos-

tic method [6]. There were some reports concerning the

curative role of endoscopic removal of IFP [17]. Small

IFP (generally 1 cm or less in size) can be safely

removed by endoscopy, but there is a possibility of local

recurrence after operation [16]. But with increasing ex-

perience in minimal access surgery, most of these tumors

are managed using endoscopic, laparoscopic, or com-

bined endoscopic and laparoscopic approache. An ex-

ception is a large submucosal lesion which can cause the

disruption of the tumor. In these circumstances, the open

procedure is a viable option. In our case, we also pre-

ferred open procedure because of the the mass was so

huge to be removed by endoscopically and we had no

sufficient experience about the laparoscopic gastric sur-

gery.

As a result, we consider that the treatment of IFP is

surgical resection and every surgeon should have suffi-

cient knowledge and experience about its diagnosis and

surgical treatment.

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